Document Detail


Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis.
MedLine Citation:
PMID:  20130832     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe.
OBJECTIVE: To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO(2))/inspired fraction of oxygen (FiO(2)) <100 mmHg] compared with moderate hypoxemia (100 mmHg < or = PaO(2)/FiO(2) < or = 300 mmHg).
DESIGN: Systematic review and meta-analysis.
DATA SOURCES: Electronic databases (to November 2009) and conference proceedings.
METHODS: Two authors independently selected and extracted data from parallel-group randomized controlled trials comparing prone with supine ventilation in mechanically ventilated adults or children with AHRF. Trialists provided subgroup data. The primary outcome was hospital mortality in patients with AHRF and PaO(2)/FiO(2) <100 mmHg. Meta-analyses used study-level random-effects models.
RESULTS: Ten trials (N = 1,867 patients) met inclusion criteria; most patients had acute lung injury. Methodological quality was relatively high. Prone ventilation reduced mortality in patients with PaO(2)/FiO(2) <100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74-0.96; p = 0.01; seven trials, N = 555] but not in patients with PaO(2)/FiO(2) > or =100 mmHg (RR 1.07, 95% CI 0.93-1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO(2)/FiO(2) thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27-39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16-1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24-2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02-9.69). There was no statistical between-trial heterogeneity for most clinical outcomes.
CONCLUSIONS: Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients.
Authors:
Sachin Sud; Jan O Friedrich; Paolo Taccone; Federico Polli; Neill K J Adhikari; Roberto Latini; Antonio Pesenti; Claude Guérin; Jordi Mancebo; Martha A Q Curley; Rafael Fernandez; Ming-Cheng Chan; Pascal Beuret; Gregor Voggenreiter; Maneesh Sud; Gianni Tognoni; Luciano Gattinoni
Publication Detail:
Type:  Journal Article; Meta-Analysis; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't; Review     Date:  2010-02-04
Journal Detail:
Title:  Intensive care medicine     Volume:  36     ISSN:  1432-1238     ISO Abbreviation:  Intensive Care Med     Publication Date:  2010 Apr 
Date Detail:
Created Date:  2010-03-12     Completed Date:  2010-06-10     Revised Date:  2011-02-23    
Medline Journal Info:
Nlm Unique ID:  7704851     Medline TA:  Intensive Care Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  585-99     Citation Subset:  IM    
Affiliation:
Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada.
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MeSH Terms
Descriptor/Qualifier:
Acute Lung Injury / mortality,  physiopathology,  therapy*
Anoxia / mortality,  physiopathology,  therapy*
Hospital Mortality
Humans
Prone Position*
Randomized Controlled Trials as Topic
Respiration, Artificial
Respiratory Insufficiency / mortality,  physiopathology,  therapy*
Grant Support
ID/Acronym/Agency:
R01NR05336/NR/NINR NIH HHS; //Canadian Institutes of Health Research
Comments/Corrections
Comment In:
Intensive Care Med. 2010 Apr;36(4):559-61   [PMID:  20130831 ]
Intensive Care Med. 2011 Feb;37(2):366-7   [PMID:  21069288 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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